“The Substance Abuse and Mental Health Services Administration (SAMHSA) is accepting applications for up to $76 million through its SAMHSA Treatment Drug Courts grant program. The money will be used to help drug courts break the cycle of criminal behavior and incarceration related to drug and alcohol use.

The purpose of the SAMHSA Treatment Drug Courts grant is to expand substance use disorder treatment services in existing adult problem solving courts and adult Tribal Healing to Wellness courts. These courts use the treatment drug court model to provide substance use disorder treatment.

SAMHSA expects to fund as many as 38 courts with up to $400,000 per year for five years. The actual awards may vary depending on the availability of funds.”

“A new study by researchers at the Johns Hopkins Bloomberg School of Public Health found that under 5 percent of those referred for opioid treatment from the criminal justice system were directed to medication-assisted programs to treat their disorder. Medication treatment, usually consisting of methadone or buprenorphine, both of which are opioids, helps control symptoms of withdrawal and cravings that can cause relapse. It is considered the most effective way to manage opioid misuse and reduce opioid-related harms such as overdose.

In contrast, the researchers found that 40 percent of clients referred for treatment by other sources, such as health-care providers, employers, or self-referral, attended medication-assisted programs. The referral gap suggests a missed opportunity to link one of the most at-risk groups of people into effective treatment at a time when the nation faces a deepening opioid crisis.”

The Department of Justice today announced $58.8 million to strengthen drug court programs and address the opioid epidemic nationwide.

About $24 million in federal grants will be awarded to 50 cities, counties and public health departments to provide financial and technical assistance to state, local, and tribal governments to create comprehensive diversion and alternatives to incarceration programs for those impacted by the opioid epidemic. These funds, awarded under the Office of Justice Programs’ Bureau of Justice Assistance’s Comprehensive Opioid Abuse Program, also included funds from the Harold Rogers Prescription Drug Monitoring Program. This program helps regulatory, law enforcement, and public health agencies address prescription drug and opioid misuse; reduce crime; and save lives.

The department is also awarding more than $22.2 million to 53 jurisdictions to support the implementation and enhancement of adult drug courts and Veterans Treatment Courts, which serve as “one-stop-shops” to link veterans with services, benefits and program providers, including the Department of Veterans Affairs, Veterans Service Organizations and volunteer veteran mentors.

“As the country reckons with an unfolding opioid crisis, and officials from both parties talk about improving access to care, jails and prisons remain treatment deserts. Few facilities provide any addiction treatment, and when prisoners are released, they return to the same environments — and the same triggers — that fostered their addiction in the first place.

Here, at its campus of squat brick buildings, the Rhode Island Department of Corrections is trying something different. Over the past year, it has expanded its so-called medication-assisted treatment program, becoming the first state system to offer such a broad range of therapies — including all three drugs approved to treat addiction — to its entire prison population.”

It has become clear that many people with opioid use disorders (OUDs) end up in jails and prisons. Immediately cut off from their source, they go into opioid withdrawal. Some of these inmates become severely dehydrated. Some who do will die if their dehydration is left untreated.

Opioid treatment programs (OTPs)—programs that offer methadone or buprenorphine—are the ideal liaisons for people with OUDs. These programs not only provide treatment for the inmates; they also educate about the important role of medication-assisted treatment (MAT) in keeping people with OUDs out of jails and prisons in the first place.

Community Medical Services (CMS) in Arizona is working with Maricopa County and the state on several key initiatives for getting medications to patients in the area’s corrections systems. The first initiative is drug courts, because they can help keep offenders from incarceration, if the offenders agree to take part in a treatment program.

Unfortunately, for too long, many drug courts have been opposed to agonist treatment. But that started to change in 2015, with an announcement by the federal government that drug courts would not receive federal funding if they categorically refused to use MAT.

After the announcement, the drug court in Maricopa County, one of the oldest in the country, started working on a plan to incorporate MAT into its system.

Nick Stavros

Still in its infantile stages—it started in December— the drug court program is already successful. “At first, the drug court was skeptical,” Nick Stavros, CEO of CMS, told AT Forum. “They wanted to see the results of starting a small number of people on methadone or buprenorphine. Within weeks they came to us and said, ‘We’re seeing patients who have never tested negative for illicit opiates actually starting to test negative for the first time.’ They were sold right away.”

Currently, CMS is treating 50 to 60 patients with MAT in the Maricopa County drug court. “We have a drug court liaison who attends drug court staffing every day to help identify MAT candidates and helps navigate them to the closest treatment program,” Mr. Stavros said.

This is a particularly sweet success story for the OTP. Until 2014, the drug court was abstinence-based, and would work only with abstinence-based providers. “But then they came to us and said OUD members’ recidivism rates were too high and showing little progress in the abstinence-based curriculums.”Jails

The drug court changes happened at about the same time that a key court decision was handed down in the county. The decision stipulated that any medical care available in the community should also be available inside local jails.

One of the strongest supporters of OTPs and methadone treatment in Maricopa county is Jeffrey Alvarez, MD. Dr. Alvarez, who has been medical director for Maricopa Correctional Health Services for more than five years, is also on the Board of Directors for the National Commission on Correctional Health Care.

“Dr. Alvarez wanted to start his own OTPs within Maricopa County jails,” said Mike White, director of community relations, and the liaison to correctional health for CMS. “Maricopa County Jails now have four internal OTPs, and are about to have a fifth.”

The Four Phases of the CountyProgram

Phase 1 of the OTP collaboration within the Maricopa County corrections system was just for pregnant women; that program started 4 years ago. The MAT operations were completely operated by CMS while offenders were provided counseling services through the Correctional Health Services Counselors.

“Our chief medical officer provided the script; we provided counseling,” said Mr. White. “You can’t bill for this in jails, so we did it without charge.” Phase 1 was carried out only for current OTP-enrolled patients who became incarcerated. Phase 2 applied to new patients: women who were pregnant, addicted to opioids, and in jail. Phase 3 covered current maintenance patients, transferred to drug court: CMS would keep them on maintenance treatment.

The current project—Phase 4—involves the OTP as soon as anyone arrested in Phoenix is in withdrawal. “Correctional Health Staff conducts a COWS Assessment upon intake and determines if the person may be appropriate for MAT, and they are then inducted on methadone inside a Maricopa County jail,” said Mr. White. (A COWS Score—an 11-item Clinical Opiate Withdrawal Scale—is used to rate and monitor common symptoms and signs of opiate withdrawal.)

When Dr. Alvarez opened his own OTPs within the jail system, CMS hand-held the operation and trained the providers on how to prescribe medications.

No More Withdrawing in Jail

In addition to getting support from Dr. Alvarez, CMS has gained the backing of the corrections staff. “They support this because it makes their lives easier,” explained Mr. White. For inmates being sent to prison, the OTP has an agreement to provide a 30-day withdrawal management program for those diagnosed with OUD.

“Kellsie Green is a story that comes to mind.” Mr. White recalls the 24-year old who died last year in Anchorage, Alaska, six days after entering jail. She was detoxing from heroin. “When instances like this occur, corrections staff end up being our biggest advocates,” said Mr. White.

When inmates in withdrawal are given tapered doses of methadone or buprenorphine, it helps mitigate the sickness, and the guards don’t spend their time “cleaning up vomit and feces. It’s easier on them. On the front end they don’t see that, but once you have a program, everyone recognizes that it’s a big improvement.”

Pre-Release to Residential Care

CMS also supports release centers for people who are offered residential services through the AZ Department of Corrections. The offenders are given the option of methadone or Vivitrol during these stabilization periods, or pre-release, or can be offered an intake upon release for buprenorphine or methadone treatment.

A parole officer sometimes gives a newly released inmate who is struggling a “time-out” in a stabilization unit or re-entry center. The person may spend anywhere from one to 90 days there. During that time, CMS can get a referral from the corrections department, and start that person in treatment in one of its clinics.

These re-entry centers are a key second chance for people who otherwise might be re-incarcerated. “Let’s say they were on parole, and started using again upon their release. They have to go in to meet with their parole officer,” explained Mr. White. “It’s voluntary to go back into custody for treatment, but if you don’t, they incarcerate you. It’s not the same as jail, it’s very much trying to be a therapeutic community. So we go into this facility and provide the MAT services.”

Vivitrol

Typically, Vivitrol has been the medication favored by criminal justice systems, where there is a longstanding bias against agonists. “In some ways, we are going down that road, too, where there is a plan to provide Vivitrol to 100 people,” said Mr. White.

“Alkermes lobbyists and sales reps are very active in Arizona,” noted Mr. Stavros. Gov. Doug Ducey, in his state-of-the-state message, called Vivitrol a “miracle drug” and announced that inmates would be offered a Vivitrol injection before their release from prison. To accommodate this order, the state asked CMS to be the Vivitrol provider.

However, the governor’s office acknowledged that the Vivitrol program hadn’t always been successful in other states. After completion of the 6-month antagonist treatment, over 90% of those treated ended up relapsing, said Mr. Stavros. “So our target is now 18 months of injections, with the first injection given before release.” Within 72 hours of release, the patient must report to CMS for comprehensive OTP services.

Eighteen months of injections, at $1,100 an injection—who is paying for this?

“Most of the integrations we’re building are either pro bono or are grant funded; CMS was awarded a 2016 MAT-PDOA grant to expand its jail in-reach program,” said Mr. Stavros. Methadone treatment itself is not expensive—about $55 to $60 a week in Arizona. But the cost of Vivitrol may not be something many jurisdictions are prepared for. “You see that in other states,” he added. “You start people on Vivitrol using a free sample that was given by Alkermes, and then when it’s time for the second shot, they start asking, ‘Who’s paying for this?’”

Mr. Stavros said the science is behind agonist treatment. “You have lay people, like correctional health employees and politicians, who prefer Vivitrol, but they pay attention to marketing and lobbying, not to research. Methadone is tried and true, but there’s little lobbying going on, and zero marketing,” he said. “Maybe some people think it’s not necessary, because methadone has the research behind it.”

Meanwhile, with the support of Dr. Alvarez and others, CMS has shown that an OTP can partner successfully with corrections systems, and that it can do so by using methadone.

“After three defendants fatally overdosed in a single week last year, it became clear that Buffalo’s ordinary drug treatment court was no match for the heroin and painkiller crisis.

Now the city is experimenting with the nation’s first opioid crisis intervention court, which can get users into treatment within hours of their arrest instead of days, requires them to check in with a judge every day for a month instead of once a week, and puts them on strict curfews.

Administering justice takes a back seat to the overarching goal of simply keeping defendants alive.

“Sending more people to prison for drug offenses won’t have an effect on drug use and deaths, according to a new analysis released this week.

Researchers from the Pew Charitable Trusts crunched state-by-state data on drug imprisonment, drug use, overdoses and drug arrests and found no evidence that they affected one another.

That lack of a pattern shows the flaw in a central philosophy in the war on drugs: That doling out harsh penalties makes people less inclined to use drugs or join the drug trade, said Adam Gelb, director of Pew’s public safety performance project, which works to reform state-level drug policies.”

“For nearly four years now, an unusual coalition of Republicans and Democrats has worked to reduce mandatory prison terms for many federal drug crimes.

But that bipartisan movement may be shallower than it appears. Indeed, Republican Sen. Chuck Grassley of Iowa and Democratic Sen. Dianne Feinstein of California, who both supported a cut-back on some drug punishments, are preparing a bill that would create tough new penalties for people caught with synthetic opioid drugs. Grassley chairs the Senate Judiciary Committee, and Feinstein is the panel’s ranking member.

A draft of the legislation reviewed by NPR suggests the plan would give the attorney general a lot more power to ban all kinds of synthetic drugs, since criminals often change the recipe to evade law enforcement. It would impose a 10-year maximum sentence on people caught selling them as a first offense. That would double if they do it again.”

“Efforts have been made to address the limited use of MAT in drug courts. In 2015, the Bureau of Justice Assistance (BJA) began requiring drug courts receiving federal funding to attest in writing that they would not deny eligible candidates access to the program because of their use of an FDA-approved medication for addiction treatment, nor would participants be required to taper off such medications as a condition of graduating from the program. In 2016, the National Drug Court Institute endorsed MAT as a best practice for treatment of opioid use disorder.

Still, adoption has been slow. Below are three well-known barriers to broader availability of MAT for drug court participants, and ways they can be overcome.”

The five-year plan of the American Association for the Treatment of Opioid Dependence (AATOD) has a goal of increasing access to care in opioid treatment programs (OTPs). Treatment “wherever it is needed”—in the United States and in the world—with the aim of patient care, is a theme running throughout the document.

The first strategic five-year plan was approved in 2001, and updated in 2007 and 2012. The current plan is for 2017-2021.

Sustainability was a guiding principle, with initiatives aimed at expanding access to OTPs, increasing access to third party funding, and working with the World Federation for the Treatment of Opioid Dependence.

Increasing OTPs

AATOD will work with its partners, including the Substance Abuse and Mental Health Services Administration (SAMHSA), to accomplish the following goals:

Identify where treatment is needed in underserved areas of the country

Identify what financial resources are needed

Work with the criminal justice, behavioral, and primary medical care systems to ensure patients receive comprehensive and coordinated care

AATOD will strive to increase care in drug courts and correctional facilities, as well as in the rest of the criminal justice system, working with the Legal Action Center and other policy partners. This year AATOD will release a criminal justice fact sheet on OTPs.

Below are other key areas highlighted by the five-year plan.

Integrated Service Delivery

The three policy papers developed by AATOD for SAMHSA last year will be the foundation for better integration of care with OTPs and other health care settings. Key to this is reimbursement from third-party payers.

Medicaid: There are still 16 states that do not allow use of Medicaid funds for OTPs. AATOD will provide guidance to help increase such reimbursement.

Medicare: Last year, the Centers for Medicare and Medicaid Services (CMS) determined that it does not have the authority to allow Medicare to pay for OTP services. The plan is for AATOD to work with the White House Office of National Drug Control Policy (ONDCP), Medicare, and Congress to make it possible for Medicare to pay for OTP treatment. Again, the leadership of the current administration will be crucial to determining the outcome of these efforts.

Commercial insurance companies: AATOD will work with commercial insurance companies on model contracts that would allow reimbursement to OTPs. There would also be cross-training opportunities so that insurance companies could better understand what OTPs do.

Working With Partners

Educating Congress: AATOD developed an educational initiative aimed at Members of Congress, some of whom don’t understand how OTPs function or what services are provided, and the misunderstanding of medications—especially methadone—needs to be rectified. This will require financial resources to coordinate how OTP administrations and patient advocates can meet with Congressional representatives both in district offices and in Washington, D.C.

Federal Agencies: AATOD will also work with federal agencies, building upon relationships with the ONDCP, SAMHSA, the Drug Enforcement Administration (DEA), the Food and Drug Administration, the National Institute on Drug Abuse, and other federal agencies. With SAMHSA, a key focus will be on cross-training initiatives, enabling OTPs to work with the states. With the DEA and SAMHSA, AATOD will focus on the Narcotic Treatment Program Guidelines, expected out during 2017.

Other Issues

AATOD will continue to promote all medications approved to treat opioid use disorders through OTPs. This is important if OTPs are to be the “essential hub treatment sites” for opioid use disorders.

Conferences, Webinars, Communications: AATOD conferences, which began in 1984, are a way to showcase leading initiatives and training to OTP staff. Conferences promote evidence-based practices and patient-centered care. Webinar-based training resources will continue to be used to advocate for AATOD’s goals. The AATOD website itself promotes new training opportunities and helps ensure wide dissemination of policy documents. There will be a mobile version of the website for access on phones and other devices.

International Work: AATOD will continue to work with the World Federation for the Treatment of Opioid Dependence and EUROPAD in increasing access to treatment. The United Nations Office on Drugs and Crime is also helping to increase resources for developing programs. Vietnam and African nations have been using PEPFAR funds to increase access to care. (PEPFAR—the President’s Emergency Plan for AIDS Relief—was created in 2003 to help certain hard-hit countries combat HIV/AIDS, TB, and malaria in hard-hit countries.) AATOD will continue to work with international and United States government organizations to promulgate evidence-based treatment.

Prescription Drug Use: AATOD will continue working with the Denver Health and Hospital Authority’s RADARS System on patterns of prescription opioid use and heroin use, and with NDRI, AATOD’s research partner, to understand how OTPs can respond to changes in drug use patterns in different parts of the country. Prescription drug monitoring programs (PDMPs) are also important to OTPs. Patient care improves when OTPs access PDMP databases. Finding out what other medications their patients are taking provides increased opportunities for counseling as well.

One of the biggest challenges OTPs have faced—and still face—is opening new facilities. This is part of the challenge AATOD is taking up: how to educate “a wary American public” to overcome the stigma of using medications to treat opioid use disorders.

“Our focus has always been to improve access to care, and when such access is available to be certain that the quality of care is evidence driven and patient centered,” the five-year plan document concludes. “It is anticipated that the next several years will continue to represent major challenges to our system. It is critically important to educate Members of Congress, state legislatures and the American public about the value of treating opioid addiction with medications based on evidence.”